• Non-vascularized bone grafts remain the mainstream treatment for scaphoid nonunion, with cancellous bone achieving healing rates of 85%-100% for non-deformed cases and corticocancellous bone providing superior structural support (88%-93%).
• Vascularized bone grafts significantly improve outcomes in complex cases, with free medial femoral condyle flaps showing a 95% healing rate and free iliac bone flaps achieving 91.7%-100% success, albeit with high technical demands.
• Distal radius donor sites have fewer complications (5%) compared to iliac crest (18%), with no significant difference in healing rates between the two.
• Individualized treatment is crucial: non-vascularized grafts suit simple fractures with good blood supply, while vascularized grafts are reserved for ischemic necrosis or complex deformities.
• Future directions include standardized MRI grading, biological enhancements (BMP-2, 3D-printed scaffolds), and wider adoption of microsurgical techniques to optimize outcomes.